Ep #145: Sexual Health Q&A with Dr. Sonia and Evelyn Resh

You are listening to The Midlife Sex Coach for Women™ Podcast episode 145.

Welcome to The Midlife Sex Coach for Women™ Podcast, the only show that combines a fun personality, medical knowledge, sexual counseling, and life coaching together. To create unique sex coaching that helps busy women awaken their libidos, address intimacy issues, and learn how to express their sexuality for the rest of their days. Here is your host, certified life coach and sexual counselor, Dr. Sonia Wright.

Alright, so good to see you. We’re so excited to have you here. And I just want to explain a couple of things. First of all I am Dr. Sonia Wright and this is Evelyn Resh who is amazing. I’m going to let her introduce all the amazing things about herself. But I just want to make sure that people understand how this call goes. So if you have any questions you can put it in the chat. It goes directly to myself and Evelyn or you can put it in the Q&A. The Q&A has a feature which is an anonymous feature.

And so any question that you want to ask then feel free to put it in the Q&A so that we can answer it for you. Either way we do not say people’s names, we’ll just read the question and we’ll answer the question and we’ll give you some coaching on it. Now, Evelyn Resh comes from the sexual health side of things. She is also a sexual counselor. She is my mentor and she is amazing in so many ways, I can’t even tell you. She’s been a midwife for over 30 years and she’s worked at Planned Parenthood for a really long time.

She is the source, any question you have she is going to be able to answer it. And I am going to just watch the pearls of wisdom drop here and collect them around me. Oh my goodness, I can’t tell you how much I love Evelyn. I am Dr. Sonia Wright. I am the midlife sex coach for women. I am a sexual counselor trained in fact by Evelyn Resh. So I was trained by the best, let me just tell you. She trains the best sexual counselors in the United States. So I am a sexual counselor. I am a Master Certified life coach. I am a medical doctor but I’m not specifically your medical doctor.

So make sure if you have any questions that you check in with your own medical providers. And I also am a toy, sex toy enthusiast. So those are all the different things. So I’m going to just check where people are calling in from and then I’m going to have Evelyn take over. So feel free to put your questions in the Q&A or in the chat if you need the anonymous feature, it’s in the Q&A. People are calling in from California, Philadelphia, Western Virginia, Western Massachusetts, Minnesota, all over the place. So it’s so good to have you here. And, Evelyn, I am going to let you take over.

We’ve even got to peek at Kansas, so good. And then also start putting your questions in the Q&A and we will get to those right away. And so, Evelyn, introduce yourself and I will [crosstalk]  some of the questions we have.

Evelyn: Well, it is always a pleasure to do these things. Dr. Wright and I are each other’s, presidents of each other’s fan clubs. And I just, I love these forums because it gives people an opportunity to ask questions that they don’t necessarily want to ask their healthcare provider or don’t have the time to ask their healthcare provider. So let me tell you a little bit about who I am in the world and the work that I do. I am 64. I have been a certified nurse midwife, which is an advanced practice nurse in women’s health for 32 years, but I’ve been in the field for 38.

And I used to do what’s called full scope practice which included doing deliveries and prenatal care, postpartum care. And then about six years ago I left the private sector doing that. And I moved into working for Planned Parenthood, and I do really enjoy that. I work for them three days a week. And then I also have this other part of my life as a sexuality counselor and I have a private practice providing consultations and teaching and forums such as this.

So a lot of what I do these days has to do with sexual health and in particular, sexually transmitted infections, which in the course of my 38 years in practice I have never seen rates as high as they are now. So when I’m talking about sexually transmitted infections, I’m talking about HPV or Human Papilloma Virus, gonorrhea, chlamydia, syphilis, HIV and then hepatitis C is attached to that although it is not specifically a sexually transmitted infection, it can be transmitted through sexual contact.

So right now, well, for the past really three and a half years, maybe four at this point, our rates of gonorrhea, chlamydia and syphilis have been staggering. And that’s a lot of what I treat. It’s a lot of what I counsel people on prevention and prevention of transmission. And I also work with HIV prevention as well. So I’m hoping that we have some questions already or perhaps you have some questions for me, Dr. Wright, maybe you do.

Sonia: One person asked in the chat, what about herpes, is that on the rise?

Evelyn: That actually is, thank you for reminding me about herpes. I mean how did that escape my mind? Yes, herpes, our prevalence and incidents have increased. And for people who don’t know the difference, the prevalence of an infection is the number of cases in a single snapshot at any given point in time. The incidents reflects the number of new cases over x period of time, so the incidents over the past 12 months, that tells you what percentage increase.

And there are definitely more cases of herpes than we’ve seen before. We have more folks in the general population who are positive for herpes, for general herpes than we’ve ever had.

Sonia: And do we know exactly why this is happening, that STIs are just on the rise, just overall?

Evelyn: Well, yeah, we do actually and there’s some interesting reasons for this. In part, sexual soirees have changed radically, I would say in the past 25 years in the United States. And part of how they’ve changed is the inclusion of hookup apps and internet dating. And one of the things that’s wonderful about the internet is the anonymity that it provides people. One of the problematic things with the internet is the anonymity it provides people. And so it’s really difficult sometimes to get a clear answer when you are dating on the internet.

Who is this person? What’s their sexual history? What are they about? Are they telling you the truth? But there’s no question that hookup apps have changed the landscape and have influenced the rates of STIs, absolutely unequivocally. And the other thing that is a constant that impacts STI rates is the fact that so many people in practice, sadly but this is true, don’t want to talk with their patients about sex.

And patients are hesitant to bring up their sexual questions because my experience has been that most patients can tell when their care provider’s uncomfortable talking about sex. And if that’s the case you’re not going to ask the questions. And in general, people’s literacy levels around sexual health are pretty low overall. And I think that that’s contributing to transmission. And people are embarrassed to get tested or they feel like why should I even think about it?

Or if they’re not of reproductive age because they’re postmenopausal they feel like, well, I don’t need to use a condom because I can’t get pregnant. Well, that would be the case but you can get a sexually transmitted infection. The other thing specific to herpes is that many people are unaware of the fact that HSV-1 which we used to specifically just consider to be an oral infection can be transmitted to a partner’s genitals. So when there’s oral genital contact and the person who’s putting their mouth on their partner’s genitals, is shedding HSV-1.

You can infect the genital area with HSV-1. Lots of people don’t realize this. So I am seeing more and more cases of genital herpes that types out to be HSV-1 and we can link it to oral sex of the partner about 10 days before.

Sonia: Okay, so that’s something that’s important to know. Now, with the introduction of PrEP, is that affecting things, like people are like, “Oh, well, now I’m not likely to die from HIV and I can prevent HIV, so I don’t need to use protective measures and things like that, is that having any influence in this situation?

Evelyn: Yeah. So we’ll separate them out. So HSV is Herpes Simplex Virus and not affected by the drugs called PEP and PrEP. HIV is Human Immunodeficiency Virus and PEP and PrEP are medications that have been out for about 10 years, well, actually maybe more like 12, that prevent the transmission of HIV. The biggest problem that I see in practice nowadays is that younger folks between the ages of teen and maybe 40, never lived through the HIV epidemic in the 80s.

And so the prevalence and the reality of HIV infection being a risk isn’t something that’s so much in their foreground. The other reality is that approximately 40,000 new cases of HIV are diagnosed a year. And it takes quite a bit of time actually before those cases are found. And why that is, is because when people go in for care their care providers aren’t asking them about their sexual practices and they’re not discussing their sexual practices.

So the people who are good candidates for PrEP to prevent HIV infection definitely can be women but the burden of those HIV infections falls on men who have sex with other men and either exclusively or bisexual men who then may go and infect a female partner.

Sonia: Okay. Alright, so we’re kind of seeing that this rise in STIs overall and it’s multifactorial.

Evelyn: It is multifactorial, absolutely. And the spread, STIs in general is multifactorial and the reason for that is because there are so many behavioral contributors such as having sex with community members in a high prevalence area. So do you live somewhere where the rates of STIs are really high and are people having sex with one another within that community? The second thing is certainly drug use and alcohol use puts people at higher risk for transmission because you’re not being as careful if you’re inebriated or you’re under the influence of all kinds of drugs.

The other thing is multiple partners, absolutely. People are very unclear about, well, I only have two partners but that’s multiple partners. And multiple partners means that whoever is having sex with your two partners by proxy, you’re having contact with their bodily fluids and a lot of people don’t realize that. So yeah, it’s always multifactorial, definitely.

Sonia: So as we’re in this age and others, most of the women in my group are in their 40s, 50s and 60s. And these hookup apps and these dating apps are coming online. And we’re in this place where we are dating in a different way than we might have done previously. Maybe we don’t have a friend that’s like, “Hey, meet this person”, or whatever. But we’re on the apps more and more. How can we prevent or what type of steps should we take when we’re taking into consideration? Because we do get to have sexual pleasure. We do get to interact with people. We do get to have fun.

But we’re also in this place where we’re not well versed on what to do in this new environment of apps and dating and things like that.

Evelyn: Yeah. So I’ll answer that and also at the same time answer one of the questions that came up in the chat about how do you know what the prevalence of STIs is in your area? And what I would say to you, given that we have so many people from so many different places in the United States, go to your state’s public health department website and see if you can find it there. Chances are high that you will be able to find it there. You might have to dig around in that website a bit.

The other option would be to go to the CDC website because they have national data. And one of the problems with the very, very decentralized nature of public health in the United States is that we don’t have a single place for me to send all of you, to say, “Okay, this is the national STD databank, go in there, put in your zip code and then presto, you’ll get information.” Because the reporting of rates of STIs is very much county and then state determined and is not necessarily fed into a national databank.

So I would start local first with your public health department for your state and see if you can find it that way. And then if you can’t, go to the CDC. The next question is, how do you prevent this? What do you do? And I think there are a few things. First of all, if you’re someone who is utilizing dating apps, I think that after every new encounter within a month after every new encounter you should have comprehensive STI testing. But before that happens, I absolutely recommend condoms.

And let me say that not all condoms are created equal. And this is of course assuming that your partner’s a male partner. But we do have female condoms. We have dental dams which are pieces of either nitrile or latex that can go against women’s genitals and prevent or block the mixing of saliva and genital secretions. And if you can’t find a dental dam you can always use a piece of Saran Wrap. You’re going to get the same sensation, you just won’t have the transmission of bodily fluids, saliva and secretions.

So number one, make sure you have regular testing and especially within a month after a new partner. The other thing is keep track of your testing. Make sure that you remember when your last testing was. And the other thing that I have some people doing with increased frequency which I think is a great idea is when you meet a new partner, to say to them, “Okay, let’s talk about our STI risks as a couple. When was the last time you were tested? Here’s the last time I was tested. Here’s my STI report card off my patient portal.”

Now, I know at Planned Parenthood we have an active patient portal. We always post the results of people’s STI testing to that portal and they can bring it up on their telephone and say, “Here’s my STI report card, I was tested last week and I haven’t had sex with a new partner since.”

Sonia: Yeah, definitely when I was in the dating world, I just would not even consider. I mean I would still use protection but I would not consider having sex with anybody until those report cards were exchanged. Women have a tendency to not feel that it’s their right to ask for this.

Evelyn: That’s absolutely true.

Sonia: [Crosstalk] making somebody upset or unhappy. What types of thoughts do you help or what type of advice do you have for women to be able to advocate for themselves and stand up for themselves?

Evelyn: Well, this might be a really funny way to put it and your audience might go, “Oh my gosh, I can’t believe she’s said this.” But what I say to people is it’s really a very simple equation. If you want to get laid you need to get tested. I want to have sex with you, you want to have sex with me, we can’t do that unless you get tested. And I don’t think that that’s such an unreasonable thing anymore.

I mean given the rates of STIs that I’m seeing and the fact that we are now dealing with some resistant strains of gonorrhea or a resistant strain of gonorrhea that has been tracked by epidemiologists to the South Pacific but made its way to the United States via Boston. We now have a strain that is not that easy to get rid of. And the bugs are always bigger than we are as we have seen over the past three years with all of the variants of COVID that we’ve dealt with.

And so I don’t think it’s such an unreasonable thing to say to someone, “I would love to have sex with you. And I need to know that you’re not carrying a pathogen that could be harmful to me. And so if you’re interested, I’m game but I need to see your report card or let’s go together. Let’s make it part of our dating experience.”

Sonia: And if it’s a person that does not want to get tested, that should be a red flag to you.

Evelyn: I agree, I absolutely agree.

Sonia: [Crosstalk], it’s not worth it, it’s not worth being in this relationship because they don’t value their own health and they don’t value your health. And in that case there’s probably a lot of other things that they’re not going to value or put you in a place of being able to take care of yourself. So you just kind of see it as you’re doing yourself a favor by not being involved with this person if they don’t want to get tested.

Evelyn: And I also think, when we’re talking about sexual pleasure, it’s very difficult to fully appreciate and experience sexual pleasure and satisfaction if you have something going like this on your shoulder all the time. Oh my God, I hope he or she isn’t infected. Oh my God, I hope they don’t have HIV. Oh no, I hope I don’t get something.” I mean it really distracts from the experience of whole body sex and whole body pleasure.

So I really do believe that we do know that the risks for women with some of these STIs are significantly greater in terms of long term damage if people get infected and it goes undetected. Because sometimes for example with chlamydia, you may not even know you have chlamydia for two or three years. And that’s a problem. That’s not so much the case with men. But the two things that women have a really hard time insisting on, sexual safety and being paid adequately.

Sonia: Yes. And I always say, how you show up in the bedroom is how you show up in your life in general. If you’re not taking care of yourself in the bedroom you’re not taking care of yourself in your everyday life and standing up for what you need. So if you’re able to demand your pleasure, your health safety, these things are key basic things, then you’re going to be able to ask for whatever else you need in life too.

Evelyn: Yeah. I do want to address a question that’s in the chat about herpes can go undetected for years. Let me be very clear because herpes is a little complicated. The average person contracts HSV-1 in the oral cavity between the ages of three and five. Now, some of you may be going, “Wait a minute, what are you talking about? Is this from sexual abuse?” No, it isn’t, it’s from relatives who have oral herpes, not realizing that when they kiss you on the cheek they can transmit it. And it’s also because kindergartners and preschoolers share utensils and cups.

So what happens in those cases is that folks who get infected as little children often have an oral outbreak but of course they don’t remember that they ever had when they’re 32 or 45 and they may never have another outbreak again. So in addressing that question of herpes can go undetected for years, in a manner of speaking, yes it can because you may have had an infection when you were a little kid, not remember it, your mother doesn’t remember it either.

And then all of a sudden you have an oral lesion and you’re thinking, well, wait a minute, who was the last person I kissed? And that’s not actually where you got it. Or you might be shedding the virus orally and you passed it to a new partner. This would be especially true if your partner was female. So yes, technically it could go undetected for years. But unless people have an actual outbreak, the recommendation is not to routinely test for it.

Sonia: That’s good information. Thank you so much for that, I appreciate it. So there’s some questions that we have in the Q&A and then I have some questions that were sent to me earlier. So one of the questions is about toys. When choosing a toy for foreplay how would you determine which toy is best in length and girth? I’m going to start with this and then I’m going to ask Evelyn to chime in. So choosing a toy for foreplay you need to recognize that it can be any type of toy for any type of concept of foreplay.

So with this one you’re talking about length and girth, it sounds like you’re adding the component of penetration in here if I’m understanding your question, which is one way to engage in foreplay. But you can also just stimulate your clitoris and your vulva region. And so there could be any type of toy that you’re interested in, it just depends on the person and what type of stimulation you would like that you enjoy. But if we’re talking about length and girth then my first thing is do no harm to yourself. So no pain, no discomfort or anything like that.

And since we have Evelyn here to ask and then also I think you need to take into consideration, are you premenopausal and postmenopausal because there’s different things that are happening here. So now that I’ve started the process and not finished the answer, I’m going to switch it over to Evelyn now for another go.

Evelyn: Okay. So what Dr. Wright is saying is really important because you don’t want to put something in your vagina in a penetrative way that’s going to be painful or for that matter, in the anus. I mean you have to make sure that you’re being careful no matter where you’re putting something. These are dilators of different sizes. I just have two hands so I’m going to be, you know, and here’s a very tiny one as you can see. So these are all different sizes. And these come from a company called Soul Source.

And these can be used for foreplay and they also can give you an idea of what you can tolerate. And to the point of whether or not you’re premenopausal, perimenopausal or postmenopausal this is going to determine your comfort level. I mean this dildo like dilator in comparison to this one, I mean this one kind of makes my hair stand on end as a 64 year old person. This one, yeah, I think I can accommodate that if that was the mood I was in. But what you need to do is that you really, you have to be careful and you have to make sure that you’re using a lubricant on whichever size you choose.

If you want to get a rough idea, let’s say you have a goal to have penetration with a particular partner. My recommendation is that you take a piece of string and you measure the length of his penis when it’s erect and then you measure the girth. And let’s say that his erect penis matches this orange prop, well, then you’re going to get those dimensions. Or if you’re looking at a sex toy catalog, you’re going to get this as your ultimate goal but you may need to start with this. Or then you can graduate to this. And then maybe you graduate to this.

And then the big boy comes in, but I think that we have to be really careful about not putting pressure on the tissue in such a way that it’s going to tear because who’s going to want to have sex under those circumstances? You won’t. So I think that you have to think, well, if I’m a person who is widowed from a heterosexual marriage and it’s been 10 years since I’ve had intercourse and my partner kind of looks like this, you’re not going to go from zero to this, nor should you expect yourself to be able to and your partner shouldn’t.

But you might be able to start with this, which is really quite small. I mean this is kind of like my finger. And sometimes these are really nice props to use for foreplay with a partner because they’re fun and they’re colorful and they’re much more interesting to use than sort of the medical grade dilators which make you feel like a patient instead of a sex partner. So I think that it’s important to kind of get a sense of the lay of the land if you will. And yes, as you’re saying, that was a great joke, the lay of the land, okay.

But as you’re saying, what condition are your genitals in, how flexible are they? Or for people who have never had a vaginal delivery. Women who have had a vaginal delivery have more sustained stretch from that entire human being coming through their vagina than a woman who’s only had a surgical birth. So there are things to consider. So I hope that answers people’s questions.

Sonia: Yeah that’s great, and I also usually add in that even when you get up to the orange prop, when you get up to that size you may still need to start at the smaller size at the beginning of the session.

Evelyn: Absolutely, that’s right. And I mean when you have an enthusiastic and very athletic partner and they’re coming at you with something like this, I mean personally you might feel like you want to run in the opposite direction but when they’re coming to you with something like that it feels like a little bit more reasonable. Okay, that’s another story altogether.

Sonia: And I might add that while you’re dilating up, there’s something called the masturbation sleeve for your friend if they’re a penis owner. So there could still be fun that is had while things are on their way to what you want them to be.

Evelyn: And I have another prop I can pull out, hang on just one minute here.

Sonia: You’ve got a toy and you’ve got a toy and you’ve got another one too. And I’m going to tell you, don’t forget, your vibrator on your clitoris. Penetration is great but adding something onto your clitoris and clitoral stimulation is fabulous because 85% of women will need some sort of clitoral stimulation in order to enjoy, have more pleasure with this. So I know our society is so focused on penetration but there’s so much more.

Evelyn: The Ohnut, I can’t seem to find my actual Ohnut. But the Ohnut, I don’t know if folks can see this on my camera. But Ohnut is O-H-N-U-T. And the Ohnut is a sleeve that’s very, very soft and flexible. You put it on the penile shaft and this is particularly helpful if you have a male partner or as Dr. Wright said, a penis owner who is very well endowed and oh, so proud about it. But meanwhile it’s coming at you and you’re going, “Oh lord.” So good, you have an Ohnut, you can…

Sonia: [Crosstalk] Ohnut, and keep talking, I will demonstrate. This is so much fun.

Evelyn: Yeah, Ohnuts are a great invention. I don’t know why we haven’t had Ohnuts in our entire lives but Ohnuts are perfect because they reduce the length and the width bit. And you can use several Ohnuts as you are witnessing as we speak. It’s like putting a little turtleneck on somebody’s penis. It’s excellent.

Sonia: It keeps them warm and comfy.

Evelyn: That’s right. It keeps them warm, and you, comfy, yeah.

Sonia: Obviously too much fun is being had here.

Evelyn: That’s right. Aren’t we serious? Yeah, I know, okay. But yeah, it keeps them warm and you, comfy.

Sonia: And it’s called an Ohnut.

Evelyn: An Ohnut, yes. And it’s really, I mean you can buy them online, there’s no restrictions or anything. It’s not a hazardous product and it’s not made of latex. So for folks who are latex sensitive, you won’t need to worry about that. And by the way, these are not made of latex either and the company is called Soul Source. And these are the only dilators that I recommend.

Sonia: Alright. Could you offer any suggestions for help with estrogen minus medications with so many side-effects? And I’m not sure if this is the same person saying, natural help for postmenopausal topical meds.

Evelyn: Okay. So let me just be clear about something. Full disclosure and complete transparency, I am a very staunch advocate of topical estrogen preparations for the genital area because you are not facing the same risks or side-effects. And in fact, the therapeutic benefits far outweigh any potential side-effects that you might experience in the beginning which can include if the tissue is quite thinned out, you can have an immediate itching response. Because you know how when you skin your knee and you get a scab and as it’s healing it starts to feel prickly and itchy underneath?

That can happen when you start to repair the tissue genitally and women will say, “Oh my God, I’m having so much itching I can’t tolerate it.” But if you can just push yourself through that phase and there are ways that you can do that, then the estrogen is repairing the tissue. But if I have someone who says to me, “Look, I just cannot, I just cannot reconcile with using a topical estrogen”, there are two products that I would recommend. One is called Bonafide B-O-N-A-F-I-D-E, you can go to their website.

And then the other one is through goodcleanlove.com. It is an aloe free vaginal moisturizer called BioNourish. And Bonafide and Good Clean Love BioNourish are the products that I would recommend. You also can use, BioNourish is a product of the Good Clean Love company. But you can also use Vitamin E cream, that is another option for some people. But just make sure that all the inert ingredients in that Vitamin E cream are okay for you to tolerate. And for people who are latex sensitive, you might also be aloe sensitive.

Sonia: So getting back to this burning sensation. Okay, so you’re using topical estrogen, and we’re putting it on our vulva as well as in our vagina, we’re putting it on our vulva. And we get a little bit of this burning sensation. How long will that generally last and how often do you recommend putting on the topical estrogen on the vulva?

Evelyn: Well, what I do is I just put in Bonafide, I’m sorry, first I spelled it wrong, okay. So what I recommend is that I have people use a cream every single night for two consecutive weeks to give them what’s called [inaudible]. So you sort of load folks up with a big dose of it and then use it in the vagina and then using it topically as well on the vulva, on the clitoris, where the, what’s called the urethral meatus, which is the opening where urine comes out of.

Then I have them back down to every other night for another two weeks and then I have them go to three times a week for the rest of their lives.

Sonia: Okay, so two weeks every day, every night and then every two weeks, every other and then after that it’s three times a week forever?

Evelyn: Yeah. And if they are experiencing significant itching then I sometimes will add a very low dose steroid cream just to give them more comfort so that the itching isn’t bugging them.

Sonia: And how long on average does the itching last for most women?

Evelyn: That’s a good question. It can be the first six to ten days. Yeah, because as the tissue is repairing and it’s getting thicker, there’s activity. You kind of can imagine that there’s stuff moving in there cellularly. And it causes some irritability and itching. And I can appreciate that it’s frustrating and uncomfortable but what I say to people is stick with it because it means that it’s doing its job.

Sonia: Okay, that’s excellent information, thank you. We have another question here, what is good for low libido? So what should we do for low libido? When you have a client that comes to you with issues of low libido, what exactly, how many different ways do you address it? What exactly do you do?

Evelyn: Well, this is a critically important question in the field of sexuality counseling and women’s sexuality because the first thing I do with people when they tell me that they have low libido is I say to them, “Tell me how you define that, what does that actually mean?” Because low libido means something very different to every single person. And the other most important thing that you have to discern is whose definition has that woman actually adopted, is it hers or is it her partner’s?

And when we’re talking about heterosexual couples the complaint of low libido is often generated by a male partner and it has nothing to do with what a woman wants. Women who say to me, “I’m fine having sex once a week and maybe twice a week but my partner feels, I mean I guess I just have low libido because he wants to be having sex three and four times a week.” And I’m saying, “Well, that would be his libido being what it is, your libido being what it is, your libido isn’t a low libido, it just happens to be yours and not his.”

And one of the biggest struggles that people have is with the idea of self-pleasuring. I mean I’ve been doing this for so many years. It is the year 2023, and yet the restrictions and the very limited thinking around masturbation is mind-blowingly apparent and really restrictive for people. And masturbating is a really healthy normal expression of sexuality for people across the spectrum regardless of gender or erotic orientation, coupled status. People’s genitals are there for them to enjoy on their very own.

So one of the things that I use as an intervention is, well, if your male partner would like to be experiencing an erection and an ejaculation five times a week he’s certainly welcome to do that on his own steam. But you don’t necessarily have a low libido because you don’t want to do what he wants to do.

Sonia: Yeah, it’s just like if you like pistachios and somebody else doesn’t like pistachios, you’re not forcing pistachios on somebody else. Everybody’s respectful of the fact that I like chocolate, I don’t like chocolate and so we don’t have it. But when it comes to sex, I find that with heterosexual relationships or partners that it doesn’t matter where the man’s sex libido is, that it’s the ‘correct libido’. And if the woman’s is lower, then she has an issue with low libido. If it’s [crosstalk] hers is higher then she’s got an over-sexual or hypersexual, these terms start coming in.

And it’s not, we’re just two individuals and with different levels of libido. So I’m going to ask the opposite question because there’s a lot more women that feel that it’s okay to ask and say there is discomfort or emotional discomfort around having a low libido. But there’s a lot of women out there that are dealing with partners a lot of times, partners, male or female and non-binary that are not interested in sex at all or very low libido and they don’t know what to do with that. So the opposite of that, if you can address what people do.

They’ll say, “I’m in a loving relationship, I have a partner that has no interest.” A lot of times it’s a male partner and they don’t know what to do because society says that men should be interested in sex all the time. And they have this higher libido, the women do and they don’t know what to do in that situation.

Evelyn: So when you look at the research on this issue of in heterosexual relationships where men have a very low or absent libido. Oftentimes it’s related to erectile function. And erectile function starts to become disappointing for the vast majority of men after they clear around age 47. They are going to start experiencing erectile difficulties. And this is related to vascular health because men have a higher prevalence of vascular disease earlier in life than women do.

And when you’ve got blood vessels that are clogged, they’re not just specifically clogged around the heart, they’re clogged body wide. And the blood vessels that go into the penis that when they fill cause an erection, also start to narrow with plaque. So what we’ve seen is that in heterosexual couples where men are not interested, it’s often related to the fact that they cannot either achieve and/or sustain an erection.

Now, what I always say to people is, “Okay, look, what you have to remember is that your most active sexual organ is your skin. It’s not your genitals, it’s your skin.” First of all your skin is your largest organ in the body and people don’t think of their skin as being an organ but it is. I mean it is the largest organ and it is your barrier against infection. It’s the way that you greet the world. It’s a very important organ. So your skin is your most important sexual organ.

And intercourse is just one of the many things that people can do that can be sexually and intimately satisfying. And if intercourse isn’t an option it doesn’t mean that pleasure is not an option also. And I work a lot with people who are aging around the idea of erotic affection. What is erotic affection? Erotic affection is laying next to each other without your clothes on and being skin to skin. It’s kissing one another. It might be showering together. It might be applying lotion on that beautiful skin after you’ve showered.

It might be holding hands while you’re watching a movie. But people have very, very intercourse centric views and when intercourse isn’t there it’s like they throw the baby out with the bathwater. Okay, I’m just looking at something in the chat. Okay, so it’s my issue, partner had a motorcycle accident that tore his uterus.

Sonia: Or urethra, is it?

Evelyn: Oh, urethra. Okay. Yeah, so this would be a fabulous opportunity for you to explore, what are the ways that you can be sexual without necessarily engaging that penile shaft. He has a scrotum. He has a perianal area, he has a back, a neck. And so I think that there are ways for people to allow their bodies to be touched that can be deeply satisfying and very much specific to that intimate relationship that are clearly sexual.

Sonia: And you also get to add on, have discussion around this because sometimes men have an idea about what it means to have or not be able to have an erection and what it means to have different toys and things. But you also get to have the penetration if that’s something that you would want. There’s a lot of fantastic dildos, there are lots of toys like that or dildos, this one’s a beautiful one. So you get to have a lot of fun and you get to have a whole different type of experience with your partner.

This doesn’t have to be by yourself. As Evelyn’s saying, you get to have it with your partner, there gets to be touch, there gets to be pleasure. You don’t necessarily need to have an erection, a man doesn’t necessarily need to have an erection in order to have an orgasm. So there’s a lot that can happen here. But what is going to be important is to have a conversation as to, does this cause discomfort? Is this why you don’t necessarily want to have an erection?

What is going on here? So that you two can come together as a team and figure out how to still have the pleasure that you need and deserve. And also make sure that your partner is comfortable and they’re not having discomfort. And when you two get to be creative with this then you figure it out and then you end up having a really beautiful and amazing sexual relationship and sexual intimacy. And really the goal I think is to have this incredible sexual intimacy that lasts into your 80s, 90s, 100.

So if you don’t have the issue now, people are going to have the issue at some point in time. So it’s okay if you’re starting to discuss and deal with this stuff now. The important thing is to keep the connection there, to keep that satisfaction there, to have the pleasure there and you get to be creative to figure out how to do this. But it does require sometimes having conversations that feel a little difficult to get a better understanding of what’s going on, what would you two like to have in the bedroom, what is not necessarily possible with their partner.

What’s causing discomfort or pain, because as soon as discomfort, pain, shame, guilt, those type of things come in then one or two partners shut it down. But if you can keep the communication open, you can definitely go from there and create this amazing sexual intimacy. And you get to create it and define it yourself.

Evelyn: That’s it, I could not agree with that more. And I think that one of the things that’s important to know is that, well, this particular participant may have a partner who had a motorcycle accident and damaged the urethra. Every single one of us is going to face some kind of challenge when it comes to sexuality at some point in our lives. And the maxim in our work is that the hardest person to talk to about sex is the person you have sex with.

I mean I know that sounds ridiculous but it’s much easier to just jump in and start touching each other’s bodies than it is to stand back and say, “Okay, how would I like to have my body touched or this is what I’d like you to do to my body.” It’s a very peculiar feature of sexuality but the one thing I would encourage people to do is that when you decide that it’s time to have a conversation about sex, don’t do it when the two of you are feeling even more vulnerable, which is in the bed without your clothes on.

You need to be talking about this when you’re having a cup of coffee and you’re sitting upright in your living room or you’re having breakfast together or you’re on a walk. And the other thing that I would say is that if you have a relationship with someone where sexuality has always been an expectation because the two of you have agreed, you are sexual partners. It is perfectly reasonable to be a partner that says, “Look, this hiatus, this moratorium on sex is not okay with me. You need to work with me here so that both of us can be sexual again in a way that works for you.

It is perfectly within your right as an established sexual partnership to be a partner in that group to say, “It’s not okay with me that sex has gone now, it’s just not. We have to find our way through this.”

Sonia: Yeah, definitely. Okay. I got another question that was emailed to me and we’ve kind of touched on a couple of these areas but I wanted to make sure that we definitely answered this question. This is a woman. She says, “Everything has changed for me. I don’t even recognize my terrain. My labia used to be long and full and they have shriveled to barely there. How can this happen? I had a terrible sexless marriage for so long that I felt dead inside, no attraction.

Now at 60 I am free and on my own. I want to find my sexuality again but I don’t even know where to start. I can’t even fit a vibrator in there anymore. Am I helpless? It feels helpless.”

Evelyn: Okay, first of all, that is a beautiful way to put it, that you don’t even recognize your terrain because in fact your terrain and the architecture of your genitals has changed. And that is true for 40 to 60% of all women who are lucky enough to be postmenopausal. However, it is shocking and it’s alarming when you look at your genitals and you think, who’s body is this? I have never seen these genitals before, what on earth is going on here? Well, what’s happened is this is the impact of ovarian retirement.

When you have less circulating estrogen, the tissue changes and in many cases, my own body, I don’t have labia minora anymore. They have just flattened, gotten really, really invisible. Well, they’re not even invisible, they’re just, I mean, yeah, they’re just not there. The architecture has changed. My terrain has changed dramatically. I’m 64. And sometimes I look at my genitals and think, oh my God, somebody came in the middle of the night and put somebody else’s body on this part of my body and it is really upsetting.

It is an adjustment. These are your genitals after ovarian retirement. And this is part of why vaginal estrogen is so important, because not only does the architecture change but the health of the tissue changes. You are not hopeless but you have to find someone who can help you with a really specific intensive vaginal estrogen reparative therapy and then stay on it, but this is not your imagination.

Sonia: She’s been in a sexless marriage for a long time. She’s now out of it and she’s trying to figure out how to find her sexuality again. I want to find my sexuality again but I don’t even know where to start.

Evelyn: Well, I mean I think that you already have started, you’re sitting in on this program. And I think that working with someone like Dr. Wright is a great way to do this. Who am I now at this stage in my life? What do I enjoy? I would encourage you to get a vibrator because what happens with vibrators for postmenopausal women is that we compensate for decreased estrogen by increasing horsepower in our stimulation and that’s what works. And any doctor who says, “This is what happens when you get older.”

Yeah, well, that’s true but it doesn’t mean that you can’t find ways of managing it and living with it more comfortably and happily. I mean when doctors say this, what I want to say especially to male doctors is, “Well, if your rectum went through significant changes like that, don’t you think you would want somebody to help you out with this?” And the answer is, of course they would. But sadly the older woman’s genitals just don’t really seem to matter to anybody except to us.

Sonia: Yeah. And I think, you know, one, because I’m a doctor and I know that we just don’t get this training in medical school or beyond, this conversation doesn’t happen. And so we get to this place where it’s default, I don’t really know what’s going on here, so I’m just going to say, “Hey, that’s what happens.” [Inaudible]. But also it’s the context of a doctor’s life in general that it’s one thing when you’re a doctor in your 30s and 40s and you’re not having to deal with this either because of your gender or your wife or partner hasn’t gotten to that stage.

But it definitely becomes much more relevant as you get older and you’re like, oh wow, yeah. Or they could be coming from a place of, “Yeah, I’m dealing with this and I don’t understand it and this is the option I think. So this is your option too.” But this is where women have to advocate for themselves.

Evelyn: Yeah. And if you don’t like the person you’ve seen for care, go to somebody else. I know it’s not easy to get in anymore.

Sonia: It is not. And I’m always happy that the baby boomers are ahead of me because they are advocating. They’re like, “This is bullshit.” I’m part of the Generation X and we’re advocating too. So by the time the millennials are going to have to deal with this, there’ll be two generations ahead that have said, “Hey, this is not right, we need to do something about this.” But we are starting to talk. We are starting to say, “Hey, we are sexual beings in our 40s, 50s, 60s, 70s, 80s, 90s, 100. We get to still be sexual beings.”

And it’s not okay to say, “This is what happens with ovarian retirement.” I have to say, I love that terminology because in my mind I just think of two ovaries at a party that says, bon voyage or good luck with your retirement or something like that.

Evelyn: My visual image is that they’re on the shores. My two ovaries are on the shores in Hawaii and they have a little My Thai in their hand. And they’re going, “Wow, we did a great job for her for a long time, now we can kick back, enjoy the ocean.” I know, I’m a very visual thinker. And when I came up with that expression, I just made myself laugh over and over again. If only I was a cartoonist, it would be perfect.

Sonia: Fabulous, definitely. And I’m 56, I’m on my own personal journey and it is a journey. I’ve been on this journey for five, six years, I’ve gone to several different. And most, I have to tell you that most of the time I am educating them. Even if say they’re at a women’s clinic, I’m still educating them. And so that can be a little disheartening but we do definitely need to keep advocating for ourselves and say, “No, this is not working, how about trying this to figure out what we need to do.” But we do get to be sexual. We do get to have pleasure.

We do get to look at our genitalia and yeah, it does change, 100%, it looks a little different than it did before. I will be doing a series on toys especially in The Lit Clit Club, which is my membership but also I just believe that toys and pleasure are something that’s so important. And as more women, maybe partnered or maybe solo partnered, we still get to have pleasure.

And so that’s something where I definitely love the toys and we get to explore and have amazing pleasure and experiences even though our bodies may be changing and the amount of stimulation that we need may be changing. But there’s still more to discover about ourselves all the time.

Evelyn: I couldn’t agree with you more and the issue about genital health and using products, moisturizers and/or estrogen, it’s not just about being able to continue enjoying pleasure, it’s also about the prevention of urinary tract infections which so often plague older women. And estrogen is what’s called bacteriostatic which means that it prevents the overgrowth of bacteria. So women who have chronic UTIs and don’t know it until they start having problems [inaudible] and they’re in the emergency room.

I mean a lot of this could be prevented by using topical estrogen for the rest of their lives after menopause and it is only available through prescription. So you have to find somebody who knows how to do this and who is willing to work with you. You can’t get it over the counter. The moisturizers are over the counter, Bonafide, BioNourish, those you can get without a prescription. Testosterone can be good for some women, that’s one of your questions. It’s really very person dependent and too big of an answer in this forum.

But the ovaries do make a percentage of testosterone, but whether or not you supplement somebody is really an individual issue and kind of a complicated decision clinically.

Sonia: Alright, I’m going to have to end this session right now. Evelyn, thank you so much.

Evelyn: A pleasure.

Sonia: And for all of you that are thinking about joining The Lit Clit Club, Evelyn Resh is going to be the person that’s in that club once a month to answer all of your questions because we need to have this. So please, all of you, join The Lit Clit Club. This month is our founding members month. So instead of the normal $97 a month, it is $67 a month through to May 31^st if you sign up and then have continuous membership or you can do a full year for $670 instead of the normal $970.

Okay, everybody, thank you so much for coming, Evelyn Resh for coming. Evelyn Resh, you are amazing and I bow as always.

Evelyn: A pleasure.

Sonia: And we’ll see you all next month in The Lit Clit Club, thank you so much.

Evelyn: Bye everyone.

                                                                                                                   

Hello, hello, hello, Diamonds, have you heard the amazing news? Dr. Sonia, that would be me and my amazing team has started a sex coaching and life coaching monthly membership program called The Lit Clit Club. The Lit Clit Club was made just for you. It’s a safe place where women can come to create the lives that they want, the lives that you want. It’s a place where you get to talk openly about your sexual concerns and be heard. There’s no judgment, no reprimand, no labels, just acceptance, knowledge and freedom.

It’s a place where you get to ask all the questions that you ever wanted to ask about sex and about life too. You get to dream big and create your life your way inside and outside the bedroom. You know I love the concept of creating the life that you want inside and outside the bedroom, that soul bursting life that you deserve. So come to the club for the sexual intimacy coaching and stay for the empowerment and the freedom.

Do you have questions about libido, menopause? Lord help us, menopause is no joke. Sexual health, relationships, sexual orientation, pleasure equality and orgasms, religion and intimacy? I am not finished with this list yet. Maybe you have questions about toys, maybe about non-monogamy. Perhaps you’re interested in BDSM, maybe self-love, self-pleasure. Maybe you have questions about self-orientation. Maybe you need to work on healing from trauma.

Maybe body image is something that you want to focus more on and definitely embodiment. Perhaps creating the life of your dreams or journeying to your authentic self. Maybe you just want to stop people pleasing. Whatever questions you have and concerns you have, we have the answers and the coaching that you need. In all actuality, you have the answers inside of you. And the coaching will help bring that out. And you know what? You get to choose how you want to be coached.

You can be coached by video, by audio only or you can use the questions and answers session, it’s whatever works for you. You get to sit back and relax and get the help that you need and your cameras are off. And every month we have a new workshop in addition to our regular coaching sessions. So click on the link below in the show notes and find out more about The Lit Clit Club. We can’t wait to see you there in the club, come join us. Things are just starting to heat up. Alright, Dr. Sonia out. Love you all, Diamonds.